• A national survey of ambulance paramedics on the identification of patients with end of life care needs

      Eaton-Williams, Peter; Barrett, Jack; Mortimer, Craig; Williams, Julia (2020-12-01)
      Objectives: Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. Methods: Between 4 November 2019 and 5 January 2020, registered paramedics from nine English NHS ambulance service trusts were invited to complete an online questionnaire. The questionnaire initially explored current practice and awareness, employing multiple-choice questions. The Gold Standards Framework Proactive Identification Guidance (GSF PIG) was then presented as an example of EoLC assessment guidance, and further questions, permitting freetext responses, explored attitudes towards performing this role. Results: 1643 questionnaires were analysed. Most participants (79.9%; n = 1313) perceived that they attended a patient who was unrecognised as within the last year of life on at least a monthly basis. Despite 72.0% (n = 1183) of paramedics indicating that they had previously made an EoLC referral to a General Practitioner, only 30.5% (n = 501) were familiar with the GSF PIG and of those only 25.9% (n = 130) had received training in its use. Participants overwhelmingly believed that they could (94.4%; n = 1551) and should (97.0%; n = 1594) perform this role, yet current barriers were identified as the inaccessibility of a patient’s medical records, inadequate EoLC education and communication difficulties. Consequently, facilitators to performing this role were identified as the provision of training in EoLC assessment guidance and establishing accessible, responsive EoLC referral pathways. Abstract published with permission.
    • A national survey of ambulance paramedics on the identification of patients with end of life care needs

      Eaton-Williams, Peter; Barrett, Jack; Mortimer, Craig; Williams, Julia (2021-03)
      Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. Abstract published with permission.
    • A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter Emergency Medical Service intervention

      Munro, Scott F.S.; Joy, Mark; de Coverly, Richard; Salmon, Mark; Williams, Julia; Lyon, Richard M. (2018-09)
    • Oxygen titration therapy and hypercapnia risk in COPD

      Harding, Cecily; Hart, Lindsay (2019-09-11)
      Background: Estimated to be the third leading cause of death in the UK by 2030, chronic obstructive pulmonary disease (COPD) is a common presenting complaint requiring an emergency ambulance. It is recognised that patients with COPD are at high risk of developing hypercapnia with the main theory of causality being high-flow oxygen therapy. Therefore, current guidelines recommend titrating oxygen therapy to maintain oxygen saturation percentage (SpO2) of 88–92% to reduce this risk. Aim: The aim of this review is to analyse literature concerning oxygen therapy in patients with COPD and their potential risk of hypercapnia. Methods: Extensive literature searches with strict parameters were carried out in electronic databases. After filtration of results, eight core articles were selected for analysis, from which three themes were identified as particular topics of interest. Findings: Critical analysis of the core articles confirmed the increased risk of hypercapnia in patients with COPD, but it is unclear if the cause is high-flow oxygen therapy, rate of alveolar ventilation or a specific COPD phenotype. Conclusion: Methods of reducing hypercapnia are limited in the prehospital setting with the only method transferable to paramedic practice being air nebulisation. Clinical compliance with study protocols and current national guidelines is low, both in prehospital and in-hospital environments. Abstract published with permission.
    • Paramedic accuracy and confidence with a trauma triage algorithm: a cross-sectional survey

      Durham, Mark (2017-03)
      Abstract published with permission. Introduction – Since 2008, the UK has been developing trauma networks, with ambulance services adopting triage tools to support these. So far there has been no published work on how UK paramedics use these algorithms. This study aims to evaluate factors affecting the accuracy and self-perceived confidence of paramedics from one UK Ambulance Trust when applying the Major Trauma Decision Tree. Methods – A quantitative cross-sectional survey was e-mailed to every paramedic within the participating Ambulance Trust, asking for basic demographic data and presenting four case studies. Respondents applied the Major Trauma Decision Tree to the case studies, stating which algorithm steps (if any) they triggered, and their appropriate destination. A Likert scale was utilised to explore respondent views on the Major Trauma Decision Tree. Descriptive and inferential statistics were used to identify linked factors affecting accuracy/confidence. Results – Of the 1132 paramedics employed by the Trust, 178 completed the survey (16% response rate). Sensitivity with the Major Trauma Decision Tree was 77% (95% CI 72–81%) and specificity, 61% (95% CI 56–66%). The trigger most commonly missed was patient age of greater than 55 years. Respondents reported that transport time to a major trauma centre/trauma unit influenced compliance with the algorithm. Self-perceived confidence was low overall, but correlated positively with frequency of exposure to trauma (rs [178] = 0.323, p < 0.0005). Respondents’ concerns about the reception they would encounter from hospital staff correlated negatively with confidence (rs [178] = –0.459, p < 0.0005). Conclusion – Respondent sensitivity when using the Major Trauma Decision Tree was low, which may be due to paramedic concerns about transport time. The most commonly missed trigger was patient age. Future training may benefit from addressing these points. In addition, respondents’ confidence with the Major Trauma Decision Tree was also low and closely linked with exposure to trauma, and the reception anticipated from hospital staff.
    • Paramedic management of shock in trauma: unlocking the potential

      Hitt, Andy (2010-08)
      Globally, traumatic injury is a leading cause of death for patients under 45 years old. A consequence of serious or poorly managed trauma is shock—a clinical syndrome that is both preventable and treatable if spotted in time. Heightened pathophysiological awareness and a review of diagnostic methods may promote early circulatory support rather than aggressive resuscitation. This could reduce the risk of iatrogenic complications and avoid unnecessary delay. The aim of this article is to critically appraise the treatment options currently available to UK paramedics and postulate realistic improvements based on underlying pathophysiology. Abstract published with permission.
    • Paramedic practitioners

      Walter, Alex (2014-02)
    • Patient assessment: a reflective case study

      Hitt, Andy (2009-12-18)
      The three ‘C's of physical assessment—capacity, consent and communication—could be compared to the ‘ABCs' of resuscitation; without all three you will make very little, if any, progress. But do we give these aspects the attention they deserve, especially in time critical situations? This case study is based on a 76-year-old female who presented at Accident and Emergency (A&E) with central chest pain, diarrhoea and vomiting, productive cough and pyrexia. The aims of this case study are to discuss the impact of 21st century legislation on patient assessment, demonstrate the importance of objective, structured history taken and investigate the subjective nature of physical examination. In a world of waiting lists and litigation some argue that we should let technology do the leg work—ultrasound, chest x-rays, magnetic resonance imaging (MRI) and computed tomography (CT)—why use a stethoscope? Abstract published with permission.
    • Patient confidentiality and safety: a classic conundrum

      Vigar, Paul (2017-05)
      Abstract published with permission. Paramedics frequently have to balance patient confidentiality and patient safety. Patient information is subject to legal, ethical and professional obligations of confidentiality and should not be disclosed to a third party for reasons other than healthcare, without consent. Whilst there is an imperative to preserve the professional/patient relationship, there are occasions where this is not possible. This article considers circumstances when confidential patient information may be disclosed without the consent of the patient and discusses the legal, ethical and professional aspects of decision making in this context. A clinical example from practice is presented where an ambulance crew was called to a 50-year-old man with type I diabetes, which is normally well controlled with insulin. He is employed as a van driver, but has experienced two sudden hypoglycaemic episodes in 3 weeks rendering him unconscious. Once treated, he declines transport to hospital, any onward referral or to inform the Driver and Vehicle Licensing Agency (DVLA) through fear of having his driving licence suspended.
    • Patient positioning and airway management in the pre-hospital setting: an observational study

      Plumbley, Stuart; Parkhe, Emma; Lambert, Ruth (2017-03)
      Abstract published with permission. Background – Pre-hospital airway management is often carried out in unconventional and challenging settings. The position of the patient requires the clinician to adjust the working position in order to get optimal visualisation. Aim and objective – This study aims to determine whether patient positioning affects the time to ventilation by tracheal intubation and the insertion of a supraglottic device in order to optimise airway management and reduce the period of hypoxia. The objective is also to compare the results of paramedics with the results of specialised critical care paramedics in order to ascertain whether additional training affects the time to ventilation in different positions. Methods – A sample of seven paramedics and seven critical care paramedics was recruited on a voluntary basis. The paramedics were timed while intubating with an endotracheal tube and inserting a supraglottic device, i-gel, from three different positions: lying down on the floor, kneeling in front of an ambulance trolley and standing with the trolley adjusted to the paramedic’s preferred height. Results – On average, both paramedics and critical care paramedics intubated from a lying down position in 26 seconds. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The quickest paramedic intubation attempt was from a lying down position in 26 seconds, whereas the quickest critical care paramedic intubation attempt from a standing position by a height-adjusted trolley took 20 seconds. Conclusion – Both paramedics and critical care paramedics intubate from a lying down position in the same time. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The critical care paramedics were more consistent in all their attempts, with less of a performance gap among themselves. The variation in time to ventilate among paramedics showed huge differences in the paramedics’ overall performance.
    • Perceived areas for future intervention and research addressing conveyance decisions and potential threats to patient safety: stakeholder workshops

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2016-09)
      Background As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention. Methods A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample. Findings The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety. Conclusions Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda. https://emj.bmj.com/content/emermed/33/9/e7.3.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2016-206139.25
    • Phase shift in transmitted electrocardiograms: A cautionary tale of distorted signals

      Tayler, David; Hitt, Andy; Jolley, Brian; Sanders, Guy; Chamberlain, Douglas (2009-08-01)
    • A pilot study evaluating the use of ABCD2 score in pre-hospital assessment of patients with suspected transient ischaemic attack: experience and lessons learned

      Munro, Scott F.S.; Rodbard, Sally; Ali, Khalid; Horsfield, Claire; Knibb, Wendy; Holah, Janet; Speirs, Ottilia; Quinn, Tom (2016-08)
    • Polytrauma: a case report

      Hitt, Andy (2011-01)
      Abstract published with permission. In the prehospital setting, the ‘foot of the bed inspection’ becomes an ‘over the ambulance dashboard inspection’. A mangled wreck at the foot of a tree is usually a good indication that someone has been injured and that timely clinical intervention may be required. By considering the mechanisms involved and performing a thorough primary survey, time critical patients can be triaged and treated with efficiency. As paramedics’ assessment skills continue to improve and doctors gain prehospital experience, it is anticipated that a well balanced team will emerge. A team that is aware of their limitations and limit their interventions to the time permitted to intervene. This case study is based on the young male driver of a vehicle that has been involved in a high speed collision with a tree. It aims to identify the probable pathologies, explain the pathophysiology of clinical signs and discuss, with evidence, the treatment options and appropriate destination for the patient.
    • PP19 Use and impact of the pre-hospital 12-lead electrocardiogram in the primary PCI era (PHECG2): mixed methods study protocol

      Munro, Scott; Gavalova, Lucia; Halter, Mary; Snooks, Helen; Gale, Chris P.; Weston, Clive; Watkins, Alan; Davies, Glenn; Hampton, Chelsey; Driscoll, Timothy; et al. (2019-09-24)
      Background The pre-hospital 12-lead electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found PHECG was associated with improved 30-day survival, but a third of ACS patients under EMS care did not have PHECG. Such patients tended to be female, older and/or with comorbidities. This previous study was undertaken when thrombolytic treatment was the main treatment for ST segment elevation myocardial infarction (STEMI); practice has since shifted to a predominant interventional strategy – primary percutaneous coronary intervention (pPCI). Moreover, the previous study relied solely on data collected by the Myocardial Ischaemia National Audit Project (MINAP), which does not include information on symptoms, EMS personnel gender, and other factors that may influence decision-making. The PHECG2 study addresses the following research questions: a) Is there a difference in 30-day mortality and reperfusion between those who do and do not receive PHECG? b) Has the proportion of eligible patients who receive PHECG changed since the introduction of pPCI networks? c) Are patients that receive PHECG different from those that do not in social and demographic factors, and in pre-hospital clinical presentation? d) What factors do EMS clinicians report as influencing their decision to perform PHECG? Methods Explanatory sequential Quan-Qual mixed methods study comprising 4 Work Packages (WPs): WP1 a population based, linked data analysis of MINAP from 2010–2017 (n=510,000); WP2 retrospective chart review of EMS records from 3 EMS; WP3 focus groups with personnel from 3 EMS. WP4 will synthesise findings from WP1-3. Conclusions Gaining an understanding into the clinical and non-clinical factors influencing EMS clinicians’ decisions to record PHECG will enable us to develop (and later test through a randomised trial) an intervention to improve PHECG uptake and patient outcomes following an ACS event., https://emj.bmj.com/content/36/10/e9.1. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2019-999abs.19
    • Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

      Bootland, Duncan; Rose, Caroline; Barrett, Jack; Lyon, Richard M.; Kent, Surrey and Sussex Air Ambulance Trust (2019-02)
      Objectives Patients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury. Design A retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS. Setting A mixed urban and rural area of 4.5million people in South East England. Participants GCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital (‘Escorted’), and those that were ‘Assisted’ but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set. Primary outcome measure Significant brain injury. Secondary outcome measure Recognition of patients requiring prehospital anaesthesia for head injury. Results Of 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04). Conclusion In patients attended by a UK HEMS service with a head injury and a GCS of 13–15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging. https://bmjopen.bmj.com/content/9/2/e023307.long This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2018-023307